Topic 1 Diabetes

DM

a chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both; affects millions of adults and is the 7th leading cause of death in the US

MC in young people, can occur at any age, S/S appear abruptly

what is the age and type of onset for type 1 DM

adults, but can occur at any age; S/S appear gradually and often go undiagnosed for many years

what is the age and type of onset for type 2 DM

type 2

what is the MC type of DM

type 1

endogenous insulin is absent it what type of DM

type 2

endogenous insulin is increased in response to insulin resistance but secretion decreases over time in what time of insulin

virus, toxins

what environmental factors lead to type 1 DM

higher weight, lack of exercise

what environmental factors lead to type 2 DM

type 1

characterized by absent/minimal insulin production

type 2

characterized by insulin resistance, decreased insulin production over time, and changes in adipokines production

• 3 P’s (polydipsia, polyuria, polyphagia)

• Fatigue

• Weight loss (without trying)

• Weakness

• Fatigue

• DKA

what are the S/S of type 1

• fatigue

• recurrent infections

• may have polyuria, polydipsia, polyphagia

• blurred vision

• recurrent vaginal yeast/candida infections

• prolonged wound healing

• vision problems

what are the S/S of type 2

type 1

ketosis are present at onset or during insulin deficiency

type 2

ketosis is usually not present and can occur during infection or high stress

type 1

insulin therapy is required for all which what type of DM

type 2

insulin therapy that might be required for some as it is a progressive disease, so it may be added to treatment plan

thin, normal, or obese

what is the body type of those with type 1

often overweight/obese with visceral adiposity (“apple shape”), may be normal

what is the body type of those with type 2

74-106 mg/dL

what is the normal range of glucose

insulin

a hormone made by the B cells in the islets of Langerhans of the pancreas that promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell which lowers glucose levels and facilitates a stable, normal glucose range

type 1

An autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic B cells that make insulin, resulting in not enough insulin for a person to survive causing those with the disease to require insulin from an outside source (exogenous insulin) to sustain life

family history, being obese, being older, being Native Americans and Alaska natives, Blacks, and Hispanics

what are the RF for type 2

type 2

characterized by a combo of inadequate insulin secretion and insulin resistance, the pancreas usually makes some endogenous insulin but it does not make enough, use it effectively, or both

prediabetes

impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), or both; an intermediate stage between normal glucose homeostasis and DM in which glucose levels are high but not enough to meet the diagnostic criteria for DM

gestational diabetes

diabetes that develops during pregnancy that leads to increased risk of C-section, perinatal death, birth injury, and neonatal complications

• A1C of 6.5% or higher

• Fasting plasma glucose (no caloric intake for at least 8 hours) of 126 mg/dL or greater

• A 2-hour plasma glucose level of 200 mg/dL or greater during an OGTT, using a glucose load of 75 g

• In a person with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss), or hyperglycemic crisis, a random plasma glucose level of 200 mg//dL or greater

what are the 4 methods that can be used to diagnose DM

• reduce S/S

• promote well-being

• prevent acute complications related to hyperglycemia and hypoglycemia

• prevent/delay the onset and progression of long-term complications

what are the goals of DM management

A1C, blood pressure, cholesterol

what are the ABCs of Diabetes

nutrition therapy, drug therapy, exercise, and BGM

what are the tools used to manage DM

insulin, oral agents, and noninsulin injectable agents

what are the three types of glucose-lowering agents (GLA) used in DM treatment

type 1

people with this type require exogenous insulin to survive

lispro (humalog), aspart (NovoLog, Fiasp), and glulisine (Apidra)

what are the types of rapid acting insulin

10-30 min

what is the onset of rapid acting (lispro) insulin

30 min-3 hr

what is the peak of rapid acting (lispro) insulin

3-5 hr

what is the duration of rapid acting (lispro) insulin

regular (Humulin R, Novolin R)

what are the types of short acting insulin

30 min-1 hr

what is the onset of short acting (regular) insulin

2-5 hr

what is the peak of short acting (regular) insulin

5-8 hr

what is the duration of short acting (regular) insulin

NPH (Humulin N, Novolin N)

what are the types of intermediate acting insulin

1.5-4 hr

what is the onset of intermediate acting (NPH) insulin

4-12 hr

what is the peak of intermediate acting (NPH) insulin

12-18 hr

what is the duration of intermediate acting (NPH) insulin

glargine

what are the types of long acting insulin

45 min-4 hr

what is the onset of long acting (glargine) insulin

no peak

what is the peak of long acting (glargine) insulin

16-24 hr

what is the duration of long acting (glargine) insulin

basal-bolus plan

insulin plan that consists of injections of rapid or short acting insulin (bolus) before meals and intermediate or long acting insulin (basal) once/twice a day to achieve a glucose level as close to normal as possible

rapid acting (lispro, aspart) insulin

this type of insulin should be injected within 15 minutes of eating

short acting (regular) insulin

This type of insulin should be injected 30-45 minutes before a meal to ensure that the insulin is working at the same time as meal absorption

intermediate acting (NPH) insulin

can be mixed with short and rapid acting insulin but it never given IV

short acting (regular) insulin

can be given IV when immediate onset of action is desired

it is inactivated by gastric fluids

why is insulin given by subcutaneous injections and not taken orally

• abdomen

• arm

• thigh

• buttock

what is the order of fastest to slowest subcutaneous absorption sites

insulin pump

delivers a continuous SQ insulin infusion through a small device worn on the body and uses rapid-acting (lispro) insulin

lipodystrophy

Changes in subcutaneous tissue that may occur if the same injection sites are used frequently

atrophy

The wasting of subcutaneous tissues that presents as an indentation in injection sites; uncommon

hypertrophy

the thickening of subcutaneous tissue that regresses if the site isn’t used for at least 6 months, injecting in this areas may cause erratic insulin absorption

Somogyi effect

too much insulin causes a patient to go hypoglycemic during the night, causing counterregulatory hormones (glucagon, epinephrine, GH, cortisol) to be released → rebound hyperglycemia and hyperglycemia n the morning

check BG at 2-4 am and if low it is Somogyi

what is the way to determine if a patient’s morning hyperglycemia is because of the Somogyi effect

headaches on wakening, night sweats, nightmares

what are side effects of the Somogyi effect

dawn phenomenon

Hyperglycemia that is present in the morning due to the excessive release of counterregulatory hormones GH the and cortisol; MC in adolescence and young adulthood due to release of GH and cortisol being released

a bedtime snack, reducing the dose of insulin, or both so the patient won’t be hypoglycemic at night and therefore won’t have rebound hyperglycemia

what is the treatment for the Somogyi effect

an increase in insulin which decreases the amount of GH and cortisol being released in the morning or an adjustment in administration time

what is the treatment for dawn phenomenon

dawn phenomenon, increase insulin

what does a client have if their BG levels from 2-4 am are high and what should the provider do

Somogyi effect, lower the amount of insulin

what does a client have if their BG levels from 2-4 am are low and S/S of hypoglycemia are present, and what should the provider do

• carbs should make up for 45% of daily intake (fruits, veggies, grains, legumes, low fat milk)

• fiber intake fo 14 g/1000 kcal a day

• adequate protein

• limit high fructose corn syrum and sugary sweetened beverages

• fats should make up 15-20% of daily intake

• limit fat and cholesterol

• limit alcohol to a moderate amount

  • 1 drink a day for women and 2 drinks a day for men

• consume alcohol with food to reduce risk of nocturnal hypoglycemia in those using insulin

• eat according to a prescribed meal plan

• do not skip meals

• eat appropriate portions

• Eat snacks mid-afternoon/bedtime to minimize glucose fluctuations

what are the nutrition recommendations for those with DM

fishing, light housework, secretarial work, teaching, walking casually

what activities are considered light activity, burning 100-200 kcal/hr

active housework, light bicycling, bowling, dancing, gardening, golf, roller skating, walking briskly

what activities are considered moderate activity, burning 200-350 kcal/hr

aerobic exercise, vigorous bicycling, hard labor, ice skating, outdoor sports, running, soccer, tennis, wood chopping

what activities are considered vigorous activity, burning 400-900 kcal/hr

150 minutes/week (30 minutes, 5 days/week) or a moderate-intensity aerobic activity and resistance training 2-3 times a week unless contraindicated

what is the ADA’s recommendation for exercise for a patient with DM

exercise

decreases insulin resistance, lowers gluoscose levels, contributes to weight loss, decreaes need for DM drugs, reduces triglycerides, LDLs, BP, increassed HDLs, improves circulation; start slowly and progress, do so 1 hour after a meal or have a 10-15 g carb snack with them, monitor BG during exercise

• doesn’t have to be vigorous to be effective

• choose things like enjoy doing

• use proper footwear

• start gradually and increase slowly

• best done after meals

• monitor BC before, during and after

• Eat a snack if BG is low before exercise beginning

• Be aware of exercise-induced hypoglycemia

what education about exercise should be given to DM patients

if BG is over 250 mg/dL and ketones are present

when should a type 1 diabetic delay activity

• aim for 150 min of moderate activity each week

• maintain a healthy weight through a nutritionally balanced diet

• follow a diet low in saturated and trans fat, total calories, and processed foods and high in whole grains, fruits, and veggies

• Have yearly screenings for DM if overweight and over age 45

• avoid smoking

• limit alcohol use to moderate levels

• follow the prescribed treatment plan for HTNl

how can DM be prevented

• increased risk for hyperglycemia

• increase caloric and noncaloric fluids

• check urine for ketones if type 1 and have a fever > 101.4 or BG is > 240 or vomiting

• speak to provider before adjusting any insulin

• always take insulin or other meds even if not eating

• test BG every 4 hours

what does sick day management include for those with DM

sweating, tachycardia, tremors

what are signs of hypoglycemia a nurse should watch for in an unconscious patient that has DM

• monitor BG at home and log/record results

• take medications as prescribed

• take insulin, especially when sick

• test A1C every 3-6 months

• S/S of hypo and hyperglycemia

• remember that exercise usually lowers BG

• make healthy food choices

• limit alcohol, soda, and fruit juice

• avoid fad diets, foods with trans and saturated fats

• have annual eye exam and influenza vaccination

• examine feet at home daily

• wear properly fitting shoes

• quit using nicotine products

• do not go barefoot

• do not apply heat/cold directly to the feet

• keep skin moisturized, but not between the toes

what are instructions for a client newly diagnosed with DM

• high glucose

• increased urinary (polyuria)

• increased appetite (polyphagia)

• increased thirst (polydipsia)

• weakness, fatigue

• blurred vision

• HA

• glycosuria

• N/V

• abdominal cramping

• progression to DKA or HHS

• mood swings

what are the S/S of hyperglycemia

• low glucose

• cold, clammy skin

• numbness of fingers, toes, mouth

• tachycardia

• emotional changes

• HA

• nervousness, tremors

• faintness, dizziness

• unsteady gait, slurred speech

• hunger

• changes in vision

• seizures, coma

what are the S/S of hypoglycemia

illness, infection, corticosteroids, too much food, too little/no DM medication, inactivity, emotional/physical stress, poor absorption of insulin

what are the causes of hyperglycemia

alcohol intake without food, too little food, too much DM medication, too much exercise without proper food intake, DM medication or food taken at the wrong time, loss of weight without a change in medication, use of β-adrenergic blockers interfering with recognition of S/S

what are the causes of hypoglycemia

if alert and can swallow immediately have the patient eat/drink 15 g of a carb, retest in 15 minutes and repeat if needed (3 time); if at home patients can give glucagon (IM) if that didn’t raise BG after 3 tries, if unconscious in healthcare setting give IV Dextrose 50% immediately

what is the Rule of 15 to treat hypoglycemia